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Appendix 1
Clinical Audit Plan 2015-2016 Quality Safety and Experience Committee 16
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CARDIFF AND VALE UNIVERSITY HEALTH BOARD
Clinical Audit: Measuring against standards to achieve
optimum care.
Clinical Audit Plan 2015/16
Appendix 1
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CARDIFF AND VALE UNIVERSITY HEALTH BOARD
CLINICAL AUDIT PLAN 2015/16
CONTENTS
1. INTRODUCTION ......................................................................................... 3
2. DEVELOPMENT OF THE PLAN ................................................................. 3
3. CARDIFF AND VALE UHB – SUMMARY of CLINICAL AUDIT PLAN
2014/15 ............................................................................................................ 4
3.1 RESOURCES ........................................................................................ 4 3.2 SKILLS AND SERVICES ...................................................................... 4
4. DETAILED CLINICAL AUDIT PLAN ........................................................... 5
4.1 CARDIFF AND VALE NCAORP PARTICIPATION ............................. 7
5. OTHER ACTIVITY .................................................................................... 27
6. EXPECTATIONS AND OUTCOMES ........................................................ 28
Clinical Audit Plan 2014-15 Page 3 of 28 Quality, Safety and Experience Committee
1. INTRODUCTION
1.1 The Clinical Audit Plan for the Cardiff and Vale University Health Board
(UHB) has been developed for 2015/16 to provide coverage of clinical audit activity across the organisation and will allow the Clinical Audit Team to provide an appropriate level of assurance to the organisation within its annual report.
1.2 The Clinical Audit Plan has been developed in accordance with Welsh Government’s directives on national audit requirements outlined in the NHS Wales National Clinical Audit and Outcome Review Plan 2015-2016 (NCAORP) and focuses on what is to be delivered. It is an accompanying document to the Clinical Audit Delivery Plan which sets out how the plan will be delivered.
1.3 The Clinical Audit Plan acknowledges the Quality Delivery Plan 2012-2016 (QDP) and signals intention to align further to the UHB clinical priorities and the Welsh Government’s Prudent Health Care agenda.
1.4 The high level summary draft plan is shown in section three with more detailed draft analysis in section four.
1.5 The plan for the year ahead describes predicted activity. It is not possible to accurately predict the detail around clinical audits required for academic curricular.
1.6 This plan provides a position statement of current activity by the clinical audit team and clinical audit activity within the Clinical Boards where known.
1.7 A separate paper describes the approach to delivering this plan
2. DEVELOPMENT OF THE PLAN
2.1 In order to optimise the use of resources the Clinical Audit Plan focuses
on National and organisational priorities in accordance with the strategic direction outlined in the QDP, the NCAORP and Welsh Government Prudent Health Care agenda. Where possible academic/professional development requirements will be aligned to these and individuals will be directed and encouraged to focus on these areas, thus maximising the use of UHB resources.
2.2 The approach to the planning process takes into account the following key
issues:
The explicit mandated priorities outlined in the QDP;
The implicit priorities alluded to in the QDP;
The mandated clinical audits in the 2015-16 NCAORP;
The alignment of UHB priorities in the quality, safety and experience agenda;
The Corporate Risk and Assurance Framework (CRAF) and its alignment to the Standards for Health in Wales;
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The academic requirements specifically of medical students and junior doctors;
Training and development of the clinical audit team to enable alignment with the quality agenda;
The logistical restrictions of notes collection and transportation;
Department functioning and interface with the rest of the organisation such as report writing and attending meetings.
3. CARDIFF AND VALE UHB – SUMMARY of CLINICAL AUDIT PLAN 2014/15
SUMMARY PLAN ANALYSIS AUDIT AREA
WTE
NCAORP audits (mandatory) 3.5
NICE and NCEPOD guidance distribution and monitoring 0.4
Other Audits/Clinical Board Support 1.0
Clinical notes collection 1.4
Administration and data inputting 0.8
Delivering training on clinical audit skills 0.2
TOTAL CARDIFF AND VALE UHB 8.0
3.1 RESOURCES The Department currently employs 8.0 WTE staff. The team comprises of:
o 4 Senior Clinical Audit Co-ordinators (3.4 WTE band 6), o 2 Clinical Audit Co-ordinators (2.0 WTE band 5), o 1 Assistant Clinical Audit Co-ordinators (0.8 WTE band 3) o 2 Clinical Audit Assistants (1.4 WTE band 2).
The managerial function for the team is the responsibility of the Quality and Safety Improvement Manager. 3.2 SKILLS AND SERVICES The team is a small but skilled workforce and offers a comprehensive range of clinical audit services for the UHB, comprised of the following:-
Critical appraisal of research literature as a precursor to developing clinical standards.
Review and adaptation of clinical guidelines for clinical audit purposes.
Development of robust project methodologies.
Application of appropriate project planning principles.
Design and development of appropriate clinical audit tools.
Clinical case note review and collation of clinical information.
Liaison with the Clinical Information Department and Clinical Coding Department to obtain appropriate patient cohorts.
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Interrogation of UHB patient information databases to extract appropriate clinical information.
Design of spreadsheets and databases specific to clinical audit tools.
Electronic data collation.
Measuring compliance with set clinical standards using appropriate analysis.
Compilation of reports and presentations to demonstrate clinical audit findings, conclusions and recommendations.
Clinical case note retrieval
Administration for ongoing audits including NICE and NCEPOD
4. DETAILED CLINICAL AUDIT PLAN AUDIT AREA WTE
Mandatory National Audits identified in NCAORP
MinaP (Myocardial Ischaemia National Audit Project) 1, 2
1.5
TARN (Trauma Audit Research Network) 1 1.2
NCEPOD (National Confidential Enquiry in to Patient Outcomes and Deaths)
0.3
Heart Failure 0.5
On-going Organisation-wide Audits
Upper GI audit Mortality Reviews and death certification database NICE administration3
0.3
0.2
0.2
Research The clinical audit team supports the all-Wales research in to measuring harm – specifically by collecting clinical case notes – 50 per month
Additional projects determined by MD
Repeat consent audit 6 months after new consent form is implemented in UHB
0.1
Academic requirements – Junior Doctors and Medical Students
Year 3, 4 and 5 medical students are expected to undertake an assignment as part of their Student Selected Component and Senior Clinical Projects, some of which are clinical audit. The number of students presenting at the department has increased considerably over the last few years. Propose set sessions for medical students and junior doctors and a move to more prospective audits aligned to other organisational priorities.
0.3
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1 Ongoing research projects – not audit cycles with actions and outcomes 2 Published on My Local Health Service 3 NICE issues guidance on a monthly basis (approximately 10 per month). The Clinical Audit Department is responsible for distributing and monitoring UHB compliance with this guidance.
Clinical Audit Plan 2014-15 Page 7 of 28 Quality, Safety and Experience Committee
4.1 CARDIFF AND VALE NCAORP PARTICIPATION Annual Programme for 2015-16 of National Clinical Audit and Outcome Reviews in which all Welsh LHBs/Trusts must participate where services provided
NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
Acute
National Joint Registry
Yes Dr Kieron Donovan
No Sept 2014 Clinical activity
of 2013 http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/NJR-11th-
Annual-Report-2014.pdf
Annual The NJR assesses compliance in two ways, one by comparing NJR submissions with the number of implants sold and the second method by comparing NJR submissions against records from the HES and PEDW which record NHS activity in England and Wales respectively.
National Emergency Laparotomy Audit
Yes Chris Morris No 14th May 2014
NELA_Org_Structures_2014.
05.14
Publishing 2017
Prospective audit of the quality of care of all patients undergoing emergency laparotomy in UK hospitals. NELA will look at structure, process and outcome measures for the quality of care received by patients undergoing emergency laparotomy. NELA will compare against standards of care such as those detailed in recent NCEPOD reports, and the Department of Health/Royal College of Surgeons of England's "Higher Risk General Surgical Patient (2011)".
Comparative Audit of Critical Care Unit Adult
Yes Dr Paul Morgan/Dr
Martyn Reed
No 2012-13 .icnarc.org/Reports/-201213-
¼ ly reports In 1994, ICNARC established the national clinical audit for adult critical care; the Case Mix Programme (CMP). Over 95% of all adult,
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
Patient Outcomes ( ICNARC )
for-adult-high-dependency-hdu-critical-
care
general critical care units in England, Wales and Northern Ireland now participate as well as an increasing number of specialist critical care services. Following rigorous data validation, all participating units receive regular, quarterly comparative reports for local performance management and quality improvement.
Trauma Audit & Research Network
Yes Dr Rupert Evans
Yes tarn.ac.uk Longitudinal study. A lot of the tragedies represented in these statistics are preventable but in the UK, as elsewhere, there is also unnecessary mortality directly due to inadequacies in the organisation and delivery of care.
Long Term Conditions
National Diabetes Audit - Adult Inpatient audit
Yes Dr Aled Roberts
Dr Lindsay
George
No Nov 2013 NDA2011-
2012Report2ComplicationsM
ortality
Oct 2014 http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/NDA-Care-
Processes-report-1-Final.pdf
30 October 2015 NPID 2014 Annual Report 30 November 2015 Annual Report 1 Clinical Processes and Treatment Targets
The National Diabetes Audit (NDA) is the largest annual clinical audit in the world, integrating data from both primary and secondary care sources, making it the most comprehensive audit of its kind. The next National Diabetes Inpatient Audit survey date will take place during the week of 21st to 25th September 2015. The audit packs which include patient and bedside questionnaires, supporting guidance and freepost return envelopes will be distributed to each participating hospital week commencing 31st August 2015. The Hospital Characteristics form will be sent by email, prior
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
2015 – complications and mortality
http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/NDA-Report-2-
Complications-and-Mortality-
Auditinteractive.pdf
to the NaDIA collection week.
Primary Care (GP)
Yes No All practices have agreed to participation.
Diabetes in Pregnancy audit
No None No http://hqip.org.uk/assets/NCA
POP-Library/CMACE-Reports/14.-
April-2010-Diabetes-in-Pregnancy-
Post-Project-Review-
Report-April-2007-
November-2009.pdf
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
Foot Care audit Patient satisfaction audit
Yes Scott Cawley No
National Diabetes Paediatric Audit
Yes No March 2015 Care
processes and outcomes
http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/2014-
NPDA-Report-1-2014-
FINAL.pdf
Feb 2014 NPDA-2011-
12-complications-
report.pdf
20 May 2015 (National Paediatric Diabetes Patient Report)
Through linkage of NHS numbers submitted to the NPDA with the Hospital Episode Statistics (HES) and Patient Episode Data Wales (PEDW) databases it has been possible to break down hospital admissions into three categories: Diabetic Ketoacidosis (DKA), hypoglycaemia and other admissions 'without complications'. The latter two categories have not previously been reported by the NPDA.
Inflammatory Bowel Disease
Yes Helen Ludlow No Sept 2014 http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/Bbiological-
therapies-
24 September 2015 (Biologics audit)
The purpose of the audit is to measure the efficacy, safety and appropriate use of biological therapies, also known as anti-TNFα therapy (Infliximab and Adalimumab) in patients with IBD in the UK and to capture the views of patients on their quality of life at intervals during their treatment.
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
Paediatric-report-Sep-
2014webFINAL.pdf
Chronic Kidney Disease in primary care
Yes Hanna Woodward
No 01 June 2015 (Pilot report)
Primary Care Audit Contract awarded May 2013 Annual primary care data extraction (similar to National Diabetes Audit); additional 4-monthly extraction and rapid feedback of key CKD performance indicators AND / OR custom-designed local feedback tool. Scope built firmly on NICE QS and Clinical Guidelines for CKD where applicable to primary care. Primary care data extraction for vast majority of data; linkage with HES (for referral rates of Stage 4) and to Renal Registry (timing of late referrals), plus proposed PREM development.
National Chronic Obstructive Pulmonary Disease
Yes Dr Simon Barry No Feb 2015 http://hqip.org.uk/assets/NCA
POP-Library/NCAP
OP-2014-15/Nat-COPD-
Audit-ProgSecondary-CareClinical-AuditNational-Full-Report-2014FINAL-PRINT.PDF
30 November 2015 (Pulmonary rehabilitation) 30 November 2015 (Secondary care)
The new audit programme brings together primary care, secondary care, rehabilitation and patient experience, marking a ground breaking, partnership approach with multidisciplinary, collaborative working to drive improvements in COPD patient care. This new audit programme supports the Department of Health (DH) aim to improve the quality of services for people with COPD by measuring and reporting the delivery of care as defined by standards embedded in guidance.
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
Renal Registry Yes No Dec 2014 https://www.renalreg.org/repo
rts/2014-seventeenth-annual-report/
Annual The UK Renal Registry provides a national source of NHS healthcare data on patients dependent on renal replacement therapy across the four nations. Using electronic reporting and substantial integration across the 71 adult and 13 paediatric renal centres independent audit and analysis of dialysis and transplant activity and care across the UK is provided.
Rheumatoid and early inflammatory arthritis
Yes Dr Anurag Negi
No 31 October 2015 (1st Annual report)
The audit will use criteria derived from the NICE Clinical Guidelines for Rheumatoid Arthritis (CG79), NICE Quality Standards for Rheumatoid Arthritis (QS33) and the recently published Best Practice Tariff (BPT) for early inflammatory arthritis which will align with NICE Quality Standards. The audit will run over continuously over the three years of the contract, covering a three month data collection period for each registered patient, and will include:
secondary care with baseline data collected at presentation, and capturing key diagnostic, management and outcomes data for the following three months;
-reported outcomes and experience, including working capacity items, with baseline data captured at presentation and at three months; and
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All Wales Audiology Audit
Jackie Harding http://gov.wales/docs/phhs/publications/150410audiologyen.
Purpose is to provide an overview to each Health Board on the performance of their paediatric audiology service(s) against the Quality Standards for Paediatric Audiology (Wales) which were launched in 2010
Mental Health
National Audit of Schitzophrenia
Yes Dr Bala Oruganti
No Oct 2014 http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/FINAL-
report-for-the-second-round-
of-the-National-Audit-
of-Schizophrenia.
October 2014
This second round of the audit re- examined the quality of prescribing, access to psychological treatments and the assessment and treatment of physical health conditions for people with schizophrenia. It also included new questions on access to support at times of crisis and help with finding work and other activities. A major finding from both rounds of the audit is the lack of monitoring and intervention for key physical health indicators for this patient group.
Women and Children
Paediatric Intensive Care (PICaNet)
Yes Dr A Wardhaugh
No Sept 14
http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/PICANet2014AnnualReportAppendices.p
df
28/09/2015 PICANet was established in 2002 and aims to continually support the improvement of paediatric intensive care provision throughout the UK by providing detailed information on paediatric intensive care activity and outcomes.
Data is collected on all children admitted to paediatric intensive care units (PICUs) across the UK. All PICUs in the UK have been supplied with bespoke software to allow data to be collected and exported to PICANet in a standardised format.
National Yes Dr R Adappa No Oct 2014 26/10/2015 The National Neonatal Audit Programme
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
Neonatal Programme Audit
http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/RCPCHNN
APReport-
(NNAP) was established in January 2006 in order to assess whether babies requiring neonatal care receive consistent care across England and Wales, identify areas for improvement and provide a mechanism for ensuring consistent high quality care in neonatal services.
Data is collected as part of the electronic daily care recording for each baby in units using the neonatal.net; a quarterly download of National Neonatal Audit Programme data items from the TNS and MANNERS systems is received.
National Childhood Epilepsy Audit
Yes Dr Francis Gibbon
No Sept 2013 CHRUKModule
-B
A succession of national reports has highlighted recurring concerns regarding the quality of diagnoses, treatment, communication and management. There is considerable variation across the United Kingdom in the way health care services currently provide for children and young people with epilepsies. The purpose of this audit is to facilitate local health services to evaluate clinical practice, patient experience and service descriptors in a standardised and meaningful way. Measures will allow service providers to identify priorities for development and benchmark good practice. Data entry for round 2 commenced in March 2013. Latest report was published in September 2013.
UK Obstetric Yes Ms A Rees & No 2013 Studies are conducted through a monthly
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
Surveillance Rachel Collis https://www.npeu.ox.ac.uk/pu
blications
UKOSS-Annual-Report-
2013
mailing to nominated clinicians in every hospital with a consultant-led maternity unit in the UK. The resulting incidence, risk factor, management and outcome information may be used for a variety of purposes including the development and audit of national guidelines and to complement the information obtained from the Confidential Enquiry into Maternal and Child Health.
Nursing
Fundamentals of Care
Yes Mandy Rayani No March 2013 wales.gov.uk/f
oc
Annual audit on every ward.
Heart
National Heart Failure audit
Yes Dr Z Yousef, Dr V Sim
Yes Nov 13 HF-2013-
Report
31 August 2015 30 November 2015
The aim of this project is to improve the quality of care for patients with heart failure through continual audit and to support the implementation of the national service framework for coronary heart disease. Complex audit carried out predominantly by clinical audit team. Supported by heart failure nurses.
Cardiac Rhythm Management Audit
Yes No March 15 http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/RCPCHNN
APReport-
This project looks at activity and trends in pacing, ICD and cardiac ablation practice in UK hospitals. Details of the type of procedures performed, who the procedure is performed by, technical success of each type of procedure and outcomes including potential complications is collected and analysed.
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
2013-FINAL-ONLINE.pdf
National Adult Cardiac Surgery Audit
Yes Prof U Von Oppell
No April 2014 http://www.ucl.ac.uk/nicor/nic
or-news-publication/NACSA_SCTSportal_update_Apr
il2014
30/09/2015 Details of who does the operations, the general health of the patients, the nature and outcome of the operation, particularly mortality rates in relation to preoperative risk and major complications are all collected and analysed.Continuous audit using electronic transfer of data from hospital systems to the central cardiac audit database.
National Audit of Percutaneous Coronary Intervention (PCI) Procedures
Yes Dr Tim Kinnaird
Yes Jan 14 Percutaneous-
Coronary-Intervention
TBC The audit collects and analyses data on the nature and outcome of PCI procedures, who performs them and the general health of patients. The audit utilises the Central Cardiac Audit Database (CCAD) which has developed secure data collection, analysis and monitoring tools and provides a common infrastructure for all the coronary heart disease audits. Continuous audit using electronic transfer of data from hospital systems to the central cardiac audit database.
National Congenital Heart Disease Audit (paediatric surgery)
Yes No Based on data exported July
2014 http://nicor4.nicor.org.uk/CHD/an_paeds.nsf/WFunnelPlots?Openview&start=1&count=500
ongoing audit – no reports
Data collected by each hospital is entered into the central cardiac audit database (CCAD) from a local client computer. This is achieved by using a CCAD supplied user interface.
Myocardial Yes Dr Tim Yes http://www.ucl. 23 October Established in 1999 in response to the national
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
Ischaemia National Audit Project (MINAP)
Kinnaird – UHW John
Thompson - UHL
ac.uk/nicor/audits/minap/documents/annual_reports/minap-public-report-
2014
2015 (The Myocardial Ischaemic National Audit Project)
service framework (NSF) for coronary heart disease, to examine the quality of management of heart attacks in hospitals in England and Wales.The UHB increased reporting from just patients who had a ST Elevated Myocardial Infarction (STEMI) to those who also had a non-STEMI.
Cardiac Rehabilitation Audit
Yes Rehabilitation Nurses
2013 cardiacrehabilitation.org.uk20
13
Managed by the rehabilitation nurses. The National Audit of Cardiac Rehabilitation is a joint initiative by the Information Centre and The British Heart Foundation (BHF).
The audit is designed to improve cardiac rehabilitation services which are known to dramatically reduce cardiac mortality and morbidity both at local and national levels. The audit takes place with an annual postal survey of organisational elements and by submission of data by cardiac rehabilitation programmes on their individual patients. Patients complete a questionnaire before, immediately after and 12 months after attending rehabilitation. Last report
National Vascular Registry Audit
Mr Richard Whiston
No Feb 2015
http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/NVRProgre
Peripheral arterial disease affects 12-14% of the general population and 20% over 70 years. It is a significant cause of disability and premature death. Clinical outcomes in the UK for major vascular interventions lag behind other European countries. There is evidence of worse outcomes following intervention for abdominal aortic aneurysm. There is wide
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
ssReport.pdf variation in limb amputation rates in patients with diabetes in England. A National Vascular Registry will be developed to audit vascular interventions for peripheral arterial disease (PAD) against agreed national standards. This will be a key part of national quality improvement programmes we will use to drive up the quality of care, by reducing variation in care delivery. The method will be to run a continuous audit using clearly defined cycles to maintain a focus both on data entry and quality of outcomes. The audit will use both real time automated reporting for units, as well as quarterly reporting to provider organisations. Annual reports will be produced to analyse national and regional progress against agreed standards and to highlight any variation in audit quality and outcomes.
Cancer
National Bowel Cancer Audit
Yes Rachel Hargest
No July 2013 http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/nati-clin-audi-supp-prog-bowe-canc-2014-
rep1.pdf
TBC Colorectal (large bowel) cancer is the most common cancer in non-smokers and second most common cause of death from cancer in England and Wales. Each year over 30,000 new cases are diagnosed, and bowel cancer is registered as the underlying cause of death in half of this number. The Welsh data is submitted directly from the Cancer Network Information System Cymru (CANISC). All Wales results but Trust/MDT level survival data.
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
National Lung Cancer Audit
Yes Dr Diane Parry No December 2014
http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/DAHNO-
2012-13-report-
11.7.14.pdf
TBC Lung cancer has the highest mortality rate of all forms of cancer in the western world and there is evidence that the UK's survival rates compare poorly with those in the rest of Europe. There is also evidence that, in the UK, standards of care differ widely. The audit was set up in response to The NHS Cancer Plan, to monitor the introduction and effectiveness of cancer services.
Suggested action plan for local use. UHL & UHW data
http://www.hqip.org.uk/lung-cancer
National Head and Neck Cancer Audit
Yes Mr Stuart Quine
No July 2014 http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/DAHNO-
2012-13-report-
11.7.14.pdf
July 2015 Head and neck cancer treatment requires a wide range of expertise, and treatment is usually discussed and agreed by multidisciplinary teams (MDTs). The aim of this audit is to produce meaningful results that act as a vehicle to improve delivery of care to patients.
National Oesophago-gastric Cancer Audit
Yes Mr Wyn Lewis No June 2013 OGCA-2013
September 2015 (date TBC) (Annual report) May 2016 (Annual
The Oesophago-gastric (stomach) Cancer audit aims to examine the quality of care given to patients and thereby help services to improve. The audit evaluates the process of care and the outcomes of treatment for all O-G cancer patients, both curative and palliative.Data can be uploaded in 2 ways: directly into the database or uploaded
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
report electronically (via CSV files) from existing information systems.
National Prostate Cancer Audit (new audit being developed)
Dr Annie Proctor
www.npca.org.uk
Nov 2014 http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/National-
Prostate-Cancer-Audit-
Annual-Report-published-Nov-
2014.pdf
30 September 2015 (Prospective annual report) 31 October 2015 (Public and Patient annual report)
The audit was undertaken by a team involving the British Association of Urological Surgeons (BAUS), the British Uro-Oncology Group and the National Cancer Intelligence Network, in partnership with the College. The National Prostate Cancer Audit in England and Wales found that hospitals are increasingly using advanced techniques to diagnose and treat men with prostate cancer.
Older People
SSNP National Sentinel Stroke Audit
Yes Dr Shakeel Ahmed (UHW)
Dr S White (UHL)
No http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/SSNAP-
Annual-Report-Apr2013-
Mar2014.pdf
8 June 2015 (Post acute organisation audit CCG report) 1 September 2015 (Post acute organisational audit National report)
The overall aim of SSNAP is to improve services by helping providers to find out where they need to do better, to enable those who manage and pay for services to monitor how well they are doing, and to empower patients, carers, stroke survivors and the wider public to call for improvements with an understanding of where they are needed.
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
30 January 2016 (Annual report) 1 November 2016 (Publication of 2016 Acute Organisational Audit Public report)
Falls and Fragility Fractures Audit Programme (incl National Hip Fracture Database)
Yes Dr Anthony Johansen
No March 2014
http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2013-14/2014-Mar-
31-onlineASAP-
FFFAP-updated.pdf
Hip Fracture
Dec 2014 http://www.hqip
19 June 2015 (Fracture Liaison Service Database – Public Report of feasibility study 2012-2014 ) 10 September 2015 (National
NHFD aims to use audit and standards to improve the quality and cost-effectiveness of hip fracture care and rehabilitation; to promote secondary prevention through the improved treatment of osteoporosis, and integrated falls services and programmes to prevent further falls; and to provide a platform for large-scale clinical trials on hip fracture care. Ongoing data collection by the hip fracture nurses.
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Clinical Audit Plan 2015-2016 Quality Safety and Experience Committee 16
th June 2015
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
.org.uk/assets/NCAPOP-
Library/NCAPOP-2013-
14/2014-Mar-31-
onlineASAP-FFFAP-
updated.pdf
Hip Fracture Database Annual Report 2015)
National Dementia Audit
Yes Dr Swapna Fernandez
No July 2013 NAD-
NATIONAL-REPORT
2017 3rd round audit. The audit will examine the care provided to people with dementia in acute hospital settings in England and Wales.
Key dates
Pilot phase and feasibility study (2015 - 2016):
January - May 2015: Review of standards and development of audit tools/surveys; establishing sampling methodology for pilot phase and feasibility study
February - May 2015: Recruitment of pilot sites
August - November 2015: Data collection for pilot and feasibility study
January - February 2016: Preliminary reporting for pilot and feasibility study sites only
Appendix 1
Clinical Audit Plan 2015-2016 Quality Safety and Experience Committee 16
th June 2015
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
Main audit (2015 - 2017):
February 2015 - February 2016: Recruitment for main audit
April - December 2016: Data collection period
April - June 2017: National reporting June - July 2017: Regional reporting November - December 2017: National
event
Pathology
SHOT – Serious Hazards of Blood Transfusion
Yes Dr A Goringe No 2013 report http://www.shot
uk.org/shot-reports/report-
summary-supplement-
2013/
SHOT is the United Kingdom’s independent, professionally- led haemovigilance scheme.
NCEPOD
MBRRACE-UK (Mothers and Babies - Reducing Risk through Audits and Confidential Enquiries across the UK)
Yes Mary Coakley No Dec 2014 http://www.hqip.org.uk/assets/
NCAPOP-Library/CORP-Library/MNI-
Reports/19Dec2014Perinatal-CDH-Report-2014-LEIC-
Almost one in 100 UK births leads to a stillbirth or newborn death and up to 100 women die each year during or just after pregnancy. The programme will investigate the deaths of women and their babies during or after childbirth, and also cases where women and their babies survive serious illness during pregnancy or after childbirth. The aim is to identify avoidable illness and deaths so the lessons learned can be used to prevent similar
Appendix 1
Clinical Audit Plan 2015-2016 Quality Safety and Experience Committee 16
th June 2015
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
2411-FINAL-Full-Report.pdf
cases in the future leading to improvements in maternal and newborn care for all mothers and babies.
Tracheostomy Care
Yes June 2014 http://hqip.org.uk/assets/NCA
POP-Library/CORP-Library/Lower-
limb-amputation-report2.pdf
To identify the remediable factors in the quality of care provided to patients who undergo a tracheostomy. 3 questionnaires – Tracheostomy insertion, critical care discharge and ward discharge. Data collection completed.
Children’s head injury
TBA - Zoe Roberts, Frances Gibbon,
No Winter 2013 (not
published as of April
2014)
Traumatic head injury is amongst the most common cause of morbidity, mortality, disability and lost years of productive life in children. http://www.hqip.org.uk/children-s-head-injury-project/
Lower limb amputation
Yes TBA Yes Nov 2014 http://hqip.org.uk/assets/NCA
POP-Library/CORP-Library/Lower-
limb-amputation-report2.pdf
Data collection completed. Aim to explore remediable factors in the process of care of patients who undergo lower limb amputation. This will include reviewing:
Pre-operative care Peri-operative care Post operative care Organisational factors
Sepsis Study Yes Dr Paul Morgan
Yes November 2015
To identify and explore avoidable and remediable factors in the process of care for patients with known or suspected sepsis. Data
Appendix 1
Clinical Audit Plan 2015-2016 Quality Safety and Experience Committee 16
th June 2015
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
collection commenced May 2014. Completed
GI Haemorrhage
Yes Dr Barney Hawthorn -
UHW Dr John Green
- UHL
Yes July 2015 To identify the remediable factors in the quality of care provided to patients who are diagnosed with an upper or lower GIH. Data collection commences Dec 2014.
Acute Pancreatitis
Yes TBA Yes June 2016 The management of this condition is usually based on clinical experience and judgement of the lead clinician in charge. This study will assess compliance with surgical guidelines for management of acute pancreatitis by evaluating current practice and highlighting areas of excellence and those areas needing improvement. Data collection expected December 2014
Provision of mental health care in acute hospitals
Yes TBA Yes Late 2016 Increasingly patients with acute mental health problems are admitted as emergencies to acute general hospitals who are not equipped to provide the special skills and treatment that these patients require. This study will review the quality of care provided to patients with a mental health disorder, who are admitted to an acute hospital. Data collection expected in 2015
New Audits under development
National Breast Cancer Audit
Currently being developed – unlikely to begin collecting data until 2016
Pain database Yes No Oct 2013 Pain-Audit-
The Pain Database improvement programme will establish the provision of specialist chronic
Appendix 1
Clinical Audit Plan 2015-2016 Quality Safety and Experience Committee 16
th June 2015
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NHS Wales National Clinical Audit Outcome Review Plan 2015-16
Specialty and Project
UHB Participation
Clinical Lead Clinical Audit Team
Involvement
Last report Date of next report
Comments
Report-2013 pain services in both secondary and primary healthcare settings and set-up a national data-set where case-mix, patient outcomes and patient experience data will be recorded. This will allow the benchmarking of services, continuous quality assurance, comparisons of case mix and provide detailed information for future service improvements and development.
Learning Disabilities
Yes Yes Sept 2014 http://www.hqip.org.uk/assets/
NCAPOP-Library/NCAP
OP-2014-15/LD-
feasability-Executive-
summmary-and-
recommendations-of-the-
NALD-report.pdf
Pilot audit completed for UHW. Over a million people in the UK have learning disability and as many as 200,000 have profound and multiple learning disabilities. People with learning disability receive less effective healthcare and have a higher rate of mortality than the general population. Major concerns have also been raised about attitudes of health and social care professionals to people with learning disability and the impact of these attitudes on the quality of care they receive. The Department of Health and the Welsh Assembly Government consider this problem to be a priority. Aims of the pilot To establish the most effective approach to measuring the quality of mental and physical health care provided to people with learning disability. This involves agreeing national standards and testing out the acceptability, reliability and validity of methods for determining to what extent these standards are being met.
Clinical Audit Plan 2014-15 Page 27 of 28 Quality, Safety and Experience Committee
5. OTHER ACTIVITY
ACTIVITY
WTE
Clinical audit database
In accordance with the UHB Clinical Audit Protocol, all clinical audit activity and outcomes should be registered with the Department. The Clinical Audit Co-ordinators are responsible for approving, subject to recognised criteria, all local project proposals received and subsequent monitoring of progress and outcome.
0.2
Annual report The Department publishes an annual report of clinical audit activity. This extensive report is extracted from the clinical audit database and after presentation to the UHB Board is available via the Cardiff and Vale intranet site.
0.2
Training others – audit methodology
6 sessions per year 0.5
Professional Development – as per PADR
Including mandatory training 0.2
Support Clinical Board Quality and Safety Meetings and activity
Continue to support Clinical Board clinical audit activity
0.4
Clinical Audit Department activity- meetings, reports, ad hoc demands
Team briefing, planning, trouble shooting. 0.2
Notes collection There is no other case note retrieval facility available for clinicians wishing to undertake a clinical audit. All case notes retrieved have to be collected and returned to their original location. 30-50% are to places across the UHB other than the file libraries. The team on average has capacity to collect around 4500 case notes. In 2014-15 over 3000 were for clinical audits managed by the clinical audit team and harm research. Notes are retrieved for medical students undertaking clinical audit as part of their medical education curriculum i
1.4
i University SIFT money contribute funding for 2.5 hours per week notes collection. In addition the Clinical Audit Team provides skills and advice to individuals and teams in clinical audit activity as part of their medical education curriculum.
Appendix 1
Clinical Audit Plan 2015-2016 Quality Safety and Experience Committee 16
th June 2015
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6. EXPECTATIONS AND OUTCOMES
The QDP is explicit that ‘Measurement is vital. It must underpin all quality improvement efforts and in seeking assurance that care is of the highest quality’….. ‘Organisations should ensure they have the capability and adequate resources to measure and present quality data to support decisions and actions to continuously improve performance and outcomes’. Welsh Government established the National Clinical Audit and Outcomes Review Advisory Committee about 3 years ago which has elevated the status of clinical audit and aligned it to support the delivery of Prudent Health Care. Health Boards are being held to account to demonstrate how the national clinical audit reports are being used to improve performance against clinical standards. A process for greater accountability within the UHB was agreed at the December 2014 Health Service Management Board. This will start with the 7 national clinical audits published on the ‘my local health services’ website. The national reports will be reviewed, summarised and discussed in meetings aligned to the quality, safety and experience committee structure where minutes are taken to provide assurance of the process. In accordance with the 6 values agreed by the UHB, clinical audit activity will focus on supporting the delivery of the NCAORP. In order for clinical audit to better support QI activity, the clinical audit team have all undertaken the Improving Quality Together Bronze level course in the past year as per the 2014-15 plan. There will be further training and development in quality improvement methodology for the team. Support and development offered by the Clinical Audit Team to junior doctors and undergraduates will continue. Current clinical audit activity will be reviewed and revised in order to release time, either within the Clinical Audit Team or in the Clinical Boards, to comply with the NCAORP. At present all the clinical audits listed in the document are either carried out by Clinical Boards with minimal support from the Clinical Audit Team apart from notes collection or not being participated in. Retrospective audit activity requiring notes collection will be limited to ensure UHB priorities are delivered and to fulfil the contractual arrangements with the University to fulfil academic requirements. Clinical audit results and recommendations must be owned and action taken at the relevant level whether it is by the individual, team, directorate or Clinical Service Board. Action plans should be developed and monitored through the appropriate the quality and safety structure. Achievements should be shared and celebrated. Joy Whitlock Quality and Safety Improvement Manager June 2015